Mentee Intake Form Contact Details Full Name First Name Last Name Preferred name Gender MaleFemale Business Name Address Street Address Street Address Line 2 Street Address Line 2 City City State/ Province Postal/ Zip Code Postal/ Zip Code Country Please select... United States Afghanistan Albania Algeria American Samoa Andorra Angola Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Replubic Chad Chile China Christmas Island Cocos (Keeling) Island Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Ethiopia Estonia Falkman Islands Faroe Islands Fiji Finland France French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadelupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Naura Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Quatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Phone Number E-mail Background Highest Level of Education Please select... High School GED Bachelor's Degree Master's Degree Doctorate How many years of work experience do you have? Please select... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Have you owned your own business? YesNo If yes, for how many years? Please select... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 What was the name of the business you owned/managed? What is the business' website? Profile Briefly describe your business: What stage is your business in: Please select... Start-up Existing Business Approximately when was your business started? Do you have a business plan? YesNo Please Upload your Business Plan: In Which industry do you operate in? Please select... Art/ Judaica Artwork Building Car Leasing Catering Cleaning Clothing Kids Clothing Women Commodities Consulting Contract Law Data Security Diamond E Commerce Event Management Finance Food Framing Furniture Graphic Artist Gutters Healthcare Healthcare Insurance High Level Computers Hospitality Insurance Sales Jewelry Large Manufacturing Makeup Marketing Odd Lot Sales Patent Law Photography Printing Process Manufacturing Property Management Publishing Real Estate Retail Roofing Sales Siding Spread Sheet Supplies Tech Toys Vitamins Wholesale Select area you feel you need help in? Please select... Finance & Accounting Government & Regulations Human Resources Intellectual Property Legal Services Manufacturing & Production Marketing Non-Profit Operations Sales Strategy & Planning Supply Chain Management Technology & IT Services Please detail what you would like to accomplish with your mentor in one sentence: How did you hear about us? Please select... Read about you in an article CHYE EPI Friend Other Need assistance with this form?